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PURPOSEStandard-dose immune checkpoint inhibitors (SD-ICIs) are the standard of care as initial therapy in microsatellite instable-high (MSI-H) advanced/metastatic colorectal adenocarcinomas (mCRC), but there are preclinical data to suggest that low-dose ICIs (LD-ICI) might also have similar efficacy.MATERIALS AND METHODSA retrospective study of patients with MSI-H mCRC receiving ICIs between June 2017 and January 2023 was conducted. The primary end point of the study was 12-month progression-free survival (PFS), which was computed using the Kaplan-Meier method.RESULTSA total of 65 patients were available for analysis during the study period. Sixty patients (92%) received nivolumab, whereas the remaining received pembrolizumab. First-line ICIs were received by 18 patients (28%), whereas 47 patients (72%) received ICIs during later lines. Thirty patients (47%) received LD-ICIs (all received nivolumab), with the remaining receiving SD-ICIs (53%). At a median follow-up of 16.5 (95% CI, 11.8 to 21.2) months, median PFS was not reached in the entire cohort. The 12-month PFS rate in the LD-ICI cohort was 90%, whereas it was 75.8% in the SD-ICI cohort. There were no statistical differences in patients receiving ICIs as first-line therapy (12 months PFS—94.4%) or during later lines of therapy (12-month PFS—77.9%; P = .56).CONCLUSIONICIs in the current study show survivals which are similar to those seen in seminal trials in patients with MSI-H mCRC. Low-dose ICIs appear to work in MSI-H mCRC and should be explored prospectively in clinical trials. Patients with MSI-H status should be exposed to ICIs, whether initially or later during treatment, whenever feasible.

In the development of image forensics, detection of Copy-Move Forgery (CMF) has become a major challenge due to the proliferation of image forgery techniques. The CMF is widely utilized to alter the content of the original image to spread false information or to use such forged digital images for illegal purposes e.g. false evidence in the court of law, or to blackmailing any individual. This paper presents a new method for CMF Detection (CMFD) that uses the power of Graph Convolution Networks (GCNs) and its multiple layers with ReLU activation, for CMFD and analysis. The aim to use GCN is due to its ability to improve the feature extraction process by utilizing the spatial and structural affiliation between elements in the digital images. Also, the GCN aims to store information about images and use it to graphically describe images with pixels or image areas as features, spatial and correlation relationships as edges. By pulling data from this image, GCN is able to obtain content rich features that are very powerful at detecting CMF regions. In proposed methodology, we utilized Support Vector machine (SVM) for classification and the binary cross-entropy loss, and the Adam optimizer for improving accuracy. Our scheme successfully achieves high accuracy and is effective in CMFD. We use the MICC F220, and CoMoFoD datasets to test the GCN in our proposed CMFD method. Through much testing and evaluation, we have found that GCN has the tremendous ability for CMFD in digital images in term of accuracy.

Introduction: The outcomes in advanced NSCLC have improved owing to the availability of more effective systemic and improved supportive care. This has increased the number of patients who seek treatment in the third line and beyond setting. We conducted this study to compare the quality of life (QoL), toxicity, and outcomes in patients receiving chemotherapy and EGFR tyrosine kinase inhibitors (TKIs) in this setting. Methods: In this phase 3, randomized, open-label study, patients with stage III or IV NSCLC with disease progression on at least two prior lines of chemotherapy, with a life expectancy of at least 3 months, without prior EGFR TKI exposure, and stable brain metastases (if any) were included. Patients were randomized to receive chemotherapy (gemcitabine or docetaxel or paclitaxel or vinorelbine) or an EGFR TKI (erlotinib or gefitinib). The primary end point was the change in QoL at 8 to 10 weeks; the secondary outcomes were safety and overall survival (OS). Patients underwent clinical evaluation at every visit, and toxicity was assessed as per Common Terminology Criteria for Adverse Events version 4.03. A radiological tumor response assessment was done every 8 to 12 weeks from the start of therapy. The QoL was assessed using the EORTC QLQ C30 and LC13 questionnaires. The change in QoL scores was calculated as the difference between scores at baseline and scores at 8 to 10 weeks (Δ) for each QoL domain. The Mann-Whitney U test was used to compare the mean difference (Δ) for each domain. OS and progression-free survival (PFS) were determined using the Kaplan-Meier method and Cox proportional regression analysis. Results: A total of 246 patients were enrolled in the study, with 123 in each arm. There was a male predominance with 69.1% male patients in the chemotherapy arm and 70.7% in the EGFR TKI arm. The median age of patients in the chemotherapy arm was 54 years and 55 years in the chemotherapy and EGFR TKI arms, respectively. There was no significant difference in the change in QoL at baseline and the second visit (Δ) in both arms in all domains of EORTC QLQ C30 except cognitive function (p = 0.0045) and LC13 except alopecia (0.01249). The mean Δ Global Health Status was −28 in the chemotherapy arm and −26.8 in the EGFR TKI arm; this was not statistically significant (p = 0.973). The median follow-up was 88.1 months (95% confidence interval [CI]: 39.04–137.15). On the intention-to-treat analysis, the median PFS was 3.13 months (95% CI: 2.15–4.11) in the chemotherapy arm and 2.26 months (95% CI: 2.1–2.43) in the EGFR TKI arm, with hazard ratio at 1.074 (95% CI: 0.83–1.38) (p = 0.58). There were 120 deaths in each arm. The median OS was 7.63 months (95% CI: 5.96–9.30) in the chemotherapy arm and 7.5 months in the EGFR TKI arm (95% CI: 5.85–9.14); hazard ratio at 1.033 (95% CI: 0.80–1.33) (p = 0.805). The toxicity profile was similar in both arms except for a significantly higher incidence of fatigue (p = 0.043), peripheral neuropathy (0.000), alopecia, hypokalemia (0.037), and pedal edema (0.007) in the chemotherapy arm and dry skin (p = 0.000) and skin rash (p = 0.019) in the EGFR TKI arm. Conclusions: There was no significant difference in most QoL scales (except cognitive function and alopecia), OS, and PFS of patients with advanced NSCLC receiving an EGFR TKI as compared with chemotherapy TKI in the third-line setting. The toxicity profile is consistent with the known toxicities of the agents.

Introduction: Delayed cord clamping (DCC) is a cost-effective delivery room intervention for better neonatal outcome. The study objective was to implement the standard practice of DCC in at least 80% of eligible neonates born by caesarean section (CS) within 2 months through multiple Plan-Do-Study-Act (PDSA) cycles. Methods: All vigorous neonates born through CS were eligible for clamping of cord ≥ 30 seconds (DCC) after birth except neonates with Rh isoimmunisation, congenital malformations, intra-uterine growth restricted fetuses with abnormal Doppler, placenta previa, abruptio placentae, cord avulsion and monochorionic-monoamniotic twins. Baseline practice of DCC in CS was observed and possible barriers elicited by fishbone analysis. Quality improvement (QI) team implemented various strategies (scientific knowledge dissemination, pre-operative planning for DCC, preventive measures for hypothermia in preterms, “cord clamp clock” in operation theatre, etc.) through a series of PDSA cycles. Timing of cord clamping (CC) was noted by a dedicated staff nurse with stopwatch. Result: Out of 112 caesarean deliveries conducted during the implementation phase, 48 and 36 deliveries were eligible for DCC during the first (PDSA-1) and the second (PDSA-2) cycle, respectively. During PDSA-1, DCC rate increased from baseline of 20% to 77% which further improved to 83.3% in PDSA-2 and 100% in the sustenance phase. The mean (SD) duration of CC during baseline, PDSA-1, PDSA-2 and sustenance phase were 13.7 (± 9.3), 30 (± 9.4), 35.2 (± 14.2), 46.6 (± 13.9) seconds, respectively. Conclusion: Implementation of best practice of DCC is challenging and needs multidisciplinary approach. Maintaining high compliance rate of DCC demands boosting confidence among perinatal team members and continued evaluation at regular intervals.

A prerequisite for nerve-sparing pelvic surgery is a thorough understanding of the topographic anatomy of the fine and intricate pelvic nerve networks, and their connections to the central nervous system. Insights into the functions of pelvic nerves will help to interpret disease symptoms correctly and improve treatment. In this article, we review the anatomy and physiology of autonomic pelvic nerves, including their topography and putative functions. The aim is to achieve a better understanding of the mechanisms of pelvic pain and functional disorders, as well as improve their diagnosis and treatment. The information will also serve as a basis for counseling patients with chronic illnesses. A profound understanding of pelvic neuroanatomy will permit complex surgery in the pelvis without relevant nerve injury.

Abstract Background Fibroids of the uterus are the most common benign pelvic tumors in women worldwide. Their diagnosis is usually not missed because of the widespread and well-established use of ultrasound in gynecological clinics. Hence, the development of an unusually large myoma is a rare event, particularly in first-world countries such as Germany. It is even more uncommon that a myoma is misdiagnosed as a dietary failure. Case presentation Herein, we report the case of a Caucasian woman with a giant fibroid that reached a size of over 50 cm, growing slowly over the past 15 years, and was misdiagnosed as abdominal fat due to weight gain. We aim to discuss the factors that lead to the growth of such a huge tumoral mass, including misdiagnosis and treatment, and the psychological impact. Through this case, we intend to increase the awareness among general physicians and gynecologists. Although menstrual disorders incorporate several pathologies, adequate assessment remains the primary responsibility of health care providers. A literature review revealed approximately 60 cases of giant uterine fibroids. Conclusion The use of clinical and diagnostic devices, especially ultrasound, in this case, is indispensable. In conclusion, the growth of a giant fibroid can have disastrous effects on a woman’s health, including surgical trauma and psychological issues.

Background: Immune check point inhibitors (ICIs) have an established role in Microsatellite- Instability--High (MSI-H) and Combined Positive Score (CPS) high advanced gastric/ gastroesophageal (G/GE) adenocarcinomas, but there is limited real world data with regard to practice patterns, and efficacy of standard doses (SD-ICIs) and alternative lower doses (LD-ICIs). Methods: A retrospective study of patients with advanced G/GE adenocarcinomas receiving ICIs was conducted. The primary endpoint of the study was 12-month overall survival (OS), which was computed by Kaplan-Meier method. Results: A total of 91 patients were available for analysis during the study period. Seventy- four patients (81%) received nivolumab, while the remaining received pembrolizumab. Fifteen patients (16%) had MSI-H status and had a 12-month OS of 60% and median OS of 15 months (median follow-up -- 38.3 months). In the Microsatellite-Stable (MSS) cohort (84%; n = 76), ICIs (combined with chemotherapy) were used predominantly in pre-treated patients (54%; n = 41). Patients with CPS ≥5 (72%; n = 55) had improved survival compared to patients with CPS <5 (28%; n = 21) (12-month OS: 52% vs. 26%; Median OS: 12.8 months vs. 3.2 months; p = 0.005). There was no difference in survival between patients who received SD-ICIs (54%; n = 41) and LD-ICIs (46%; n = 35) (12-month OS: 42% vs. 48%; Median OS: 8.7 months vs. 11 months; p = 0.44). Conclusions: Patients with advanced G/GEJ adenocarcinomas in the real world predominantly received ICIs during later lines of therapy as opposed to first line therapy. Using a CPS cutoff of ≥5 as opposed to CPS <5 predicts for improved survivals in MSS patients and patients receiving low dose ICIs have similar survival outcomes to patients receiving standard dose ICIs within the confines of a heterogenous study cohort. [ABSTRACT FROM AUTHOR]

Background: Gallbladder cancer (GBC) is one of the leading cancers among gastrointestinal malignancies. GBC occurs more frequently in females worldwide. There are very few studies on the incidence of GBC in the state of Rajasthan. The present study evaluates its temporal variation and area-wise distribution. Materials and Methods: Five-year retrospective data on GBC incidence were obtained from Hospital-Based Cancer Registry of Regional Cancer Centre (RCC), Bikaner, from January 2014 to December 2018. Linear regression was applied to determine the trend of GBC incidence over these 5 years. District- and tehsil-wise distribution of patients was also analyzed. Results: Of 31,553 cases registered at RCC, Bikaner, from January 2014 to December 2018, there were 1199 cases of GBC accounting for 3.8% of the total. Among these, there were 333 males and 866 females which contributed approximately 1.8% and 6.4% of all male and female cancer cases, respectively. The median age at the diagnosis of GBC was 60 years in both the sexes. Linear regression analysis showed an increasing trend of GBC incidence over 5 years. The highest incidence rate was found in the districts of Sri Ganganagar, Hanumangarh, and Bikaner, with most patients coming from Ganganagar and Suratgarh tehsils of Sri Ganganagar district. Conclusion: GBC cases have shown an increasing trend in the past 5 years in Rajasthan with a higher incidence in the North-Western districts irrigated by canal water. There is a need to correlate the water chemistry and find out solutions for reducing the risk of GBC in future.

A variety of procedures have been used for family planning. One of these is sterilization surgery, which can be reversed by a tubal reanastomosis. In the present report, we compare Robot-assisted tubal reanastomosis sterilization with other methods of family planning and discuss factors related to the choice of the approach. The keywords used for the electronic search in PubMed were family planning, sterilization, Robot-assisted, tubal reanastomosis, depression, and regret. The decision in favor of or against sterilization surgery has been a sensitive issue for several years. Robot-assisted technology is a modern and precise approach. It has contributed to the flexibility of the decision between sterilization and its reversal through tubal reanastomosis, as well as enhanced the success rate of the surgery. Based on our analysis of the published literature, we believe that Robot-assisted tubal anastomosis is the optimum approach. However, to ensure the quality of health care, the surgeon must be well trained, well versed with the anatomy of the fallopian tubes, and thoroughly informed on the psychological impact of family planning.

Abstract Unicornuate uterus with pregnancy in the noncommunicating rudimentary horn is extremely rare. Diagnosis requires awareness, high suspicion index, 3D ultrasound, and MRI. If missed, it can be catastrophic. Treatment varies across literature. We present a case where detection was done by 3D ultrasound and primary laparoscopic surgery done for treatment.

Background: For the assessment of fixed-dose combinations of Dapagliflozin and Metformin Hydrochloride in bulk pharmaceuticals and pharmaceutical formulations utilizing distilled water as a solvent, a novel, straightforward, precise, and accurate UV-spectrophotometric absorbance correction approach was devised. On the additive absorbance property, an absorbance correction method was based. Materials and Methods: By keeping Dapagliflozin and Metformin hydrochloride apart, a distinct spectrum was generated, displaying absorption maxima peaks (max) at 275nm (DAPA), and 245nm (MET). Compared to metformin hydrochloride, dapagliflozin displayed some absorbance at 275nm. At 245nm, both drugs exhibit absorption. A method for solving equations is based on measuring the absorbance of two wavelengths, 275nm, and 245nm. Exactly validating the procedure was done. Dapagliflozin and metformin hydrochloride concentration ranges of 2-10 µg/mL and 20-100 µg/mL, respectively, were used in the assays utilizing the absorbance correction method at 275nm and 245nm, respectively. Results: The mean recovery for each compound was 100.25 + 0.0459% and 99.82 + 0.059. The accuracy (RSD 2%) was discovered to be within bounds. This approach had precise and accurate optical properties. The proposed method can be used with pharmaceutical formulations, and it was unaffected by the usual excipients included in the formulation. Conclusion: The findings demonstrate that the method is practical for routine estimation of the fixed-dose combination of dapagliflozin and metformin hydrochloride, in a pharmaceutical dosage form. It is straightforward, conscious, accurate, and applicable. [ABSTRACT FROM AUTHOR]

Burkholderia is a gram-negative bacillus causing infections in immunocompromised patients. It is commonly seen in the tropics and is known to mimic tuberculosis clinically. Six patients were reviewed who were admitted in our hospital between July 2018 to June 2019 after obtaining their consent. All the six patients were uncontrolled diabetics with HbA1c levels between 8.2-13.9% who presented with fever more than 2 weeks and had abdominal symptoms like vomiting, abdominal pain or loss of appetite. Some also had respiratory symptoms like cough, chest pain and breathlessness. All of them had leucocytosis (neutrophilic). Mild transaminitis was also observed. CT abdomen revealed presence of multiple hepatic and splenic abscesses in all the patients. Chest X-ray revealed bilateral pneumonia in five patients. Burkholderia cepacia was found in the blood of four patients, sputum of one patient and splenic pus aspirate of one patient. Four patients were treated with meropenem and rest with ceftazidime. All of them responded well to treatment and became asymptomatic. Ultrasonography abdomen at follow-up was negative for any intra-abdominal abscesses. They were also put on long term oral co-trimoxazole. The clinical presentation of Burkholderia closely mimics tuberculosis as it predominantly affects immunocompromised and causes a long-duration multi-systemic illness. There has been several case series of intra-abdominal abscesses caused by Burkholderia pseudomallei but infections by Burkholderia cepacia in the abdomen is a rare finding. The diagnosis of burkholderia is often delayed due to its inconspicuous nature, lack of clinical suspicion and often mimicking tuberculosis clinically.

Introduction: The estimated prevalence of Hypomagnesemia in Type 2 Diabetes Mellitus (T2DM) ranges between 14% to 48% in various studies. Hypomagnesemia has been found to be associated with increased insulin resistance in patients of T2DM. Aim: The aim was to estimate fasting serum magnesium levels in the patients of T2DM and to correlate serum magnesium with glycaemic status and nephropathy status. Materials and Methods: It was a cross-sectional study conducted at KIMS, Bhubaneswar between October 2017 to September 2019 which included a total of 187 T2DM patients. The glycaemic status was assessed by HbA1c and subdivided into good (HbA1c 9%). The nephropathy status was assessed by urine Albumin-Creatinine Ratio (ACR) and subdivided into macroalbuminuria (Urine ACR >300 mg/g), microalbuminuria (Urine ACR 30-299 mg/g) and non-nephropathy (Urine ACR

Eighty percent of leg ulcers have a vascular aetiology. These ulcers are often debilitating for the patients and difficult to treat owing to lack of clinical suspicion leading to significant morbidity and mortality. Here we report a case of bilateral leg ulcers in a young female with Anti Phospholipid Syndrome (APS). She also had associated Evans’ syndrome in the absence of lupus. She responded well with oral anticoagulant and immunosuppressives on follow-up after 6 weeks and 12 weeks. Thus, APS should be kept in mind while evaluating a case with leg ulcers in a young patient as in the present case.

BACKGROUND AND OBJECTIVE: Thrombocytosis is not an uncommon finding in hemograms of children with an incidence of 6%–15% among hospitalized children. This study aims to determine the etiology of thrombocytosis and analyze various platelet parameters in children attending our hospital. MATERIALS AND METHODS: A prospective observational study was carried out in a tertiary care center in Odisha, in eastern part of India, for 6 months from July 2016 to December 2016. All children of age group 1–14 years of age attending pediatrics and other pediatric super specialty outdoors and/or admitted to indoors and whose complete blood counts (CBC) were done were included in the study. The CBC parameters such as hemoglobin, red blood cell indices, and platelet indices (platelet distribution width [PDW], mean platelet volume [MPV], platelet large cell ratio [P-LCR]) were noted. RESULTS: Out of 2500 hemograms done in pediatrics age group, 272 (10.8%) patients showed thrombocytosis. About 99.6% of cases were of secondary thrombocytosis. Only one case of primary thrombocytosis was encountered. The most common cause of secondary thrombocytosis was infection (39.5%) alone followed by iron deficiency anemia (14.1%). With increasing platelet counts, a decrease in MPV, P-LCR, and PDW was noted which was statistically significant (P < 0.05). CONCLUSION: Thrombocytosis is not rare (10.8%) in children. Secondary thrombocytosis is common and predominatly attributed to infection.